Provider Demographics
NPI:1477548527
Name:DETTMER, THOMAS A (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:DETTMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6436 RED BARN
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3069
Mailing Address - Country:US
Mailing Address - Phone:573-552-8569
Mailing Address - Fax:573-348-2747
Practice Address - Street 1:5962 HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3338
Practice Address - Country:US
Practice Address - Phone:573-552-8569
Practice Address - Fax:573-348-2747
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT03438OtherLICENSE
000091213Medicare ID - Type Unspecified
MOT03438OtherLICENSE
MA2410002Medicare PIN